A practitioner’s guide to emphasizing choice-making opportunities in behavioral services provided to individuals with intellectual and developmental disabilities

Abstract

Promoting choice is a defining value guiding Positive Behavior Support (PBS) models for serving individuals with intellectual and/or developmental disabilities (IDD). The ability to make independent choices is of paramount importance to self-advocacy and self-determination. Promoting choice is also an essential commitment of trauma-informed care (TIC) in the provision of services to vulnerable individuals, as trauma often involves experiences in which an individual has no control over aversive events that occur, and choice-making opportunities can empower traumatized individuals to regain control over the environments they routinely encounter. However, incorporating meaningful choice making into behavioral programming is often more difficult than it seems. We synthesize the relevant, contemporary literature to provide professionals with actionable suggestions for incorporating choice making into everyday behavioral services. After summarizing the importance of promoting choice into behavioral services based on the values that define both PBS and TIC frameworks, we (a) offer a behavior-analytic interpretation of the skill of making choices, (b) synthesize key literature on how to teach choice making skills, (c) provide recommendations for the situations within one’s care in which choice-making opportunities may be most beneficial, and (d) discuss some of the barriers and potential solutions to incorporating choice-making opportunities for individuals with IDD.

Person-centered planning is at the heart of any positive behavior support plan (Gore et al. 2013). Ensuring that an individual’s needs, preferences, and values are at the forefront of identifying target behaviors, setting goals, and selecting support strategies is essential for meeting the person-centered mandate. Further, actively involving an individual in their own support planning has the potential to develop repertoires of self-advocacy and self-determination while simultaneously acknowledging the importance of such repertoires. However, determining what a person wants or values, or which strategies are most acceptable to them, can be difficult because (a) verbal reports may not always be reliable indicators of preference (Cohen-Almeida et al. 2000), and (b) some individuals have limited functional communication. These barriers have driven the development of a range of behavior-analytic strategies aimed at improving intervention outcomes and overall quality of life by way of determining what an individual wants or values. For example, various functional analysis approaches have been developed over the past four decades that effectively identify the consequences that reinforce challenging behavior (Beavers et al. 2013, Iwata and Dozier 2008). These strategies are predicated on the assumption that most behavior serves a communicative function (Hanley 2012); therefore, such analyses convincingly answer questions about individual needs by telling us what a particular response or response class communicates for that person. In a similar vein, a range of preference assessment strategies (Tullis et al. 2011, Verriden and Roscoe 2016) have been developed to give voice to individuals who might otherwise struggle to make their preferences known. Outcomes of these assessments often are used to identify stimuli that may function as effective reinforcers for skill acquisition or behavior reduction procedures (DeLeon et al. 2001) or to enrich a person’s living or learning environment (Gover et al. 2019).

Although functional analyses and preference assessments acknowledge and actively pursue information about individual needs, they often function as ‘one-time’ assessments on which other strategies might be built. As such, they are necessary but not sufficient for person-centered planning in which the individual is actively and consistently involved in treatment decisions. Achieving such engagement, and thus promoting autonomy and self-determination, requires teaching specific skill repertoires (Agran et al. 2010, Burke et al. 2020). Perhaps chief among those skills is choice making.

Many organizations that support people with intellectual disabilities strongly advocate for the incorporation of choice into every aspect of support planning (e.g. British Institute on Learning Disabilities, n.d.; Inclusion Australia, n.d.; The Arc, n.d.). The importance of enabling choice making cannot be overstated as it is a critical means of facilitating and upholding fundamental human rights such as communication, education, healthcare, recreation, and employment. For example, the United Nations Convention on the Rights of Persons with Disabilities (CRPD; 2006b) includes in its guiding principles, ‘respect for inherent dignity, individual autonomy including the freedom to make one’s own choices, and independence of persons’ (italics added). Furthermore, the convention agreed that ‘parties shall take effective and appropriate measures, including through peer support, to enable persons with disabilities to attain and maintain maximum independence, full physical, mental, social, and vocational ability, and full inclusion and participation in all aspects of life’ (Article 26; CRPD, 2006a). That choice making is universally seen to be linked to a multitude of human rights speaks to the importance of teaching choice-making skills and creating choice-making opportunities throughout all aspects of one’s care.

Further, choice making is a key component of most trauma-informed care (TIC) frameworks. Across many professions that serve vulnerable populations, TIC refers to commitments and practices aimed at acknowledging and simultaneously minimizing the potential for retraumatizing individuals who may have experienced traumatic events at some point in their life. TIC models prescribe a set of strategies for mitigating trauma while facilitating participation in the therapeutic process. In some cases, trauma can result in reduced sense of control, lack of confidence, and inhibition with respect to in independent decision making (Gurwitch et al. 2002). As such, a key commitment is encouraging the autonomy of individuals receiving care to the extent possible, which may be facilitated via the provision of choice and the sharing of governance regarding the development of services (Keller-Dupree 2013). Both are intended to enable the individual to have as much control over their environment as reasonably possible, thereby restoring experienced and perceived autonomy in their life. Although empirical evidence is presently lacking in support of the assertion that emphasizing choice making promotes self-determination, multiple researchers have appealed to the logic that providing choices necessarily increases a sense of control and autonomy (relative to having no choices), thereby imbuing compassion during service delivery and likely reducing potential retraumatization (Guarino et al. 2009, Keller-Dupree 2013).

Choice is pervasive in everyday experience; most people make several dozen choices even before they leave their houses in the morning—when to wake up, what to wear, what to eat for breakfast, and which route to take to school or work. They also make choices that may have substantial implications for significant aspects of their lives, including where to live, who to live with, where to work or study, and with whom they will entrust the most personal aspects of their lives. For individuals with intellectual and developmental disabilities (IDD), however, opportunities to make even simple choices for oneself are often much more limited (Bannerman et al. 1990). From a logistical perspective, this may be a matter of good risk management, as balancing a person’s right to choose with the consequences of particular choices can be difficult (Braye et al. 2017). Indeed, choices might be intentionally restricted because the person frequently makes decisions that are not (or are not seen to be) in their best interest. These choices might prove dangerous not only for the individual, but for those charged with their care. For example, if a person chooses not to shower, dress, or engage in other hygiene or household cleaning duties for several days or weeks, this may pose concerns regarding personal health or safety. For care providers, provision of choice in this instance could possibly be construed as neglect.

The exigencies of providing services to individuals with IDD may stack the deck against certain choices, often for pragmatic reasons. However, a caregiver or service provider’s duty of care must be balanced with the ‘dignity of risk’ for every individual (Marsh and Kelly 2018). Said another way, it is a fundamental human right, often protected by law, for individuals to be allowed to make choices that may or may not be in their best interest. Typically developing individuals are usually free to make choices that may be detrimental to their health or personal safety, but individuals with IDD are commonly at greater risk to be stripped of such liberties due to the presumption that they may not know better (Bannerman et al. 1990, Cobb 1973, Schloss et al. 1993). Thus, progressing toward a human rights-based model of support requires careful consideration of the risks and benefits associated with offering or withholding certain choice-making opportunities.

Moreover, beyond the notion that choice is a basic human right and that its restriction limits opportunities to autonomy and self-determination, the research on choice has provided several compelling reasons why it should play a key role in support planning for people with disabilities. For example, the act of choosing may improve motivation to engage with tasks or reduce occurrences of challenging behavior (Howell et al. 2019). Further, a strong preference for choice has been demonstrated in research involving humans and nonhuman animals (e.g. Catania 1975, Thompson et al. 1998). This means that, when offered either single or multiple options to produce reinforcement, individuals tend to consistently choose the latter.

Being able to express one’s preference is critical to achieving self-determination (Burke et al. 2020, Wehmeyer et al. 2004), which suggests that (a) choice-making opportunities should be abundant within one’s care and (b) choice-making repertoires should be explicitly taught when they are deficient. Although allowing ‘small choices’ throughout the day, such as what socks to wear or what cereal to eat for breakfast, is better than nothing, it is perhaps not much better (Agran et al. 2010). We argue that the behavior-analytic literature has provided a wealth of strategies for integrating choice across various aspects of daily life, including substantial life choices such as which therapeutic approach to engage with (or whether to engage at all). The primary purpose of this paper is to distill much of the choice-making research into practical guidelines for care providers. Importantly, we address the language that is used around choice and suggest how the ways we talk about choice might influence the development of choice technologies. We sample literature that sought to teach choice-making skills and summarize recommendations for how to approach such skill deficits. We also provide clinical guidance pertaining to the conditions in which promoting choice-making opportunities may be most prudent and beneficial across the course of support provision. We conclude with a discussion of the possible risks associated with providing too much choice and provide recommendations to mitigate such risks.

What does choice making entail?

Before determining how and when a practitioner might incorporate choice-making opportunities into a support plan, it is important to differentiate between choice and preference. In much of the disabilities literature, choosing and choice making are commonly defined as the selection of one stimulus among two or more alternatives according to one’s preference at the time of selection (e.g. Agran et al. 2010, Martin et al. 2006). This definition suggests that that we make choices because of our inherent preferences. The notion that one’s momentary preference could serve as a causal explanation for any given choice may render some interpretive difficulty in that one’s preference must be inferred from the choices made, which could lead to circular reasoning. As such, behavior-analytic definitions typically disentangle choice from preference; whereas choice is considered the independent emission of one response among many, often incompatible, response alternatives in any given moment, preference is typically determined when one choice is successively made more frequently than others (Catania 1975, Rajaraman et al. 2022). Whereas choice making is a behavioral response sensitive to momentary environmental factors and one’s learning history, preference can only be gleaned after successive choice-making opportunities have been presented. Some researchers have even argued that all volitional behavior could be conceptualized as choice in that we are always making a choice to behave with respect to one stimulus, either in comparison to another, or by choosing to not behave with respect to that stimulus (Baum 1972, Borrero and Vollmer 2002). The functional distinction between choice and preference becomes important when individuals fail to demonstrate the skill of choice making in relevant situations. In other words, for us to know the preferences of the individuals we serve, we must be assured that they have the skills to make choices that express those preferences.

So what component skills are required to properly express one’s preference through successive choices? Choosing requires that an individual can discriminate among options given and engage in some sort of selection response indicating the choice made. Speaking loosely, this means that an individual should be able to tell the difference among options (and their associated outcomes) upon initial presentation of the options. Because preference can only be expressed across multiple choice-making opportunities, to express a preference suggests not only that an individual can tell the difference between the options presented to them, but that they have experienced the different outcomes associated with each choice. The former reflects a capacity to detect differences in stimuli; the latter reflects an understanding of the consequences associated with each choice (Tessing et al. 2006).

Despite the likelihood that choice-making opportunities are more limited for individuals with IDD relative to typically developing peers, the range of potential choices offered can span across broad dimensions. In some cases, choosing may appear a rudimentary selection among stimuli tangibly presented in front of the individual for them to interact with. For example, if asked to pick what to wear when presented with jeans and trousers, choosing behavior may take the form of vocally stating one (e.g. ‘trousers’) or otherwise selecting (e.g. touching, pointing to) trousers in the presence of both jeans and trousers. If an individual were to choose trousers routinely when presented with this option, we might say that they prefer trousers. More often, the choice presented is among stimuli to be included into reinforcement contingencies that will be arranged with the express purpose of changing the individual’s behavior in a particular situation (e.g. reinforcers to be earned during academic instruction; DeLeon et al. 2001). For example, we may conduct a preference assessment by repeatedly presenting action figures, puzzles, and a tablet in a systematic manner. When we observe that an individual routinely selects the tablet when presented with these options, we may infer their preference and may arrange for the tablet to be delivered as a reinforcing consequence to teach certain skills. Some choices may be narrow in their scope, such as which activity to complete first or who to play a game with, whereas others may be broader, such as which type of behavioral intervention to receive or whether or not to participate in behavioral services. Choice-making skills are required to make all the above decisions, and choice-making opportunities are required for such decisions to be made.

In sum, choice making entails (a) being presented with options, (b) detecting the difference among those options, and (c) engaging in some sort of selection response toward one option. Expressing a preference further entails experiencing the outcomes of each option and being provided repeated choice-making opportunities to express that one option is preferred over another.

How can we facilitate choice making?

Authentic choice making requires that an individual evaluate options and select the one that is most preferred. However, despite the provision of options, some individuals with IDD struggle to make selections or might repeatedly select a particular option that may or may not be reflective of their actual preferences. For example, when offered raisin bran or yogurt for breakfast, an individual might consistently select raisin bran, despite having never tried yogurt. In situations where a person does not make a choice or appears to be selecting without truly knowing what they are saying ‘no’ to, it may be useful to consider designing programs that support individuals in developing core choice-making skills.

At its most basic level, the inability to make choices may be reduced to a failure to discriminate among available options. It is important to note that we do not mean to imply that inability reflects a deficiency of the individual; rather, the behavior-analytic perspective suggests that insufficient demonstration of a skill reflects inadequate opportunities for those skills to be acquired and rehearsed. For example, such difficulties may stem from insufficient exposure to the outcomes of certain choices, which limits the capacity for those choices to be differentially reinforced. It is difficult for an individual to know if they like yogurt if they have never tried it. Likewise, it is difficult for an individual to know if they like corn flakes if they cannot readily detect how they are different from raisin bran. A common and somewhat intuitive method of offering choices in everyday practice is to present options vocally (e.g. ‘would you like to do this or that?’). Although this may be sufficient for some, responses to vocal options may not reliably indicate one’s preferences. For example, Cohen-Almeida et al. (2000) and Wilder et al. (2003) demonstrated that providing vocal descriptions of options, as opposed to pictures or objects from which to choose, reliably resulted in selection of items that were ultimately found to be insufficiently reinforcing and less preferred. In short, vocal presentation of choice-making opportunities may not always be enough.

Regardless of how options are presented, individuals with known deficits in communication may struggle with the component skill of detecting the difference among options presented. Multiple studies have evaluated whether experiencing the consequences of a certain selection impacts one’s ability to make particular choices and, more broadly, indicate their preference (Hanley et al. 1999, Higbee et al. 1999, Tessing et al. 2006). These studies have collectively demonstrated that access to the outcomes of one’s choices is an important element to expressing preference in that differential access (compared to no access) almost always resulted in the identification of more reinforcing preferences, suggesting that discrimination can be facilitated through the experience of differential outcomes.

Parsons and Reid (1990) provided an early example of this approach, whereby they presented two food options simultaneously, instructed participants to sample each food item by placing it in their mouth, and subsequently asked the individual to pick one option between the two. This procedure was successful in teaching choice-making that generalized across multiple settings. In a follow-up study, Reid and Parsons (1991) successfully incorporated such choice-making opportunities into routine mealtimes, thereby enabling their participants to express more food and drink preferences during meals.

Another procedure for facilitating discrimination among options involves the use of a concurrent chains arrangement, in which different stimuli (e.g. colored pieces of paper) are first presented in one context, each of which are correlated with the opportunity to experience a subsequent, unique reinforcement context (Hanley 2010). Procedures surrounding this arrangement typically start with an individual repeatedly experiencing the reinforcers and reinforcement schedule that follow each initial selection. They are then provided with the initial options concurrently (i.e. all at once) to permit choice-making and an ultimate expression of preference. Responses to the initial stimuli are often designed to be low effort (e.g. touching one piece of paper), but they importantly permit the individual to engage in a discrete response reflective of a choice made. By contrast, terminal responses within the unique, terminal reinforcement contexts can range broadly in terms of the type and amount of behavior required. The differences arranged in each terminal situation are those among which the individual chooses and ultimately displays a preference.

Many studies have used microswitches, a technology that requires a low-effort response, as an initial response to facilitate discrimination among two or more outcomes (e.g. Kennedy and Haring 1993, Lancioni et al. 2011, Stasolla et al. 2013). In a recent example that included simple initial and terminal responses to teach relatively simple discriminations, Stasolla et al. (2013) introduced a pressure-sensitive microswitch that enabled three children with multiple disabilities—who did not make selections by way of other response topographies—to select between food, drink, and leisure items presented on a computer screen. The arrangement did not initially require that the children actively scanned and chose among options; rather, children could press the microswitch when one of the options was lit up on a screen, and this selection resulted in a subsequent screen where options within the category were presented. Selection of an item resulted in the delivery of that item for the child’s consumption. Stasolla et al. not only showed that the microswitch enabled preferences to be expressed across categories of items and activities with which to engage, but that the experienced outcomes of choices made were correlated with increases in indices of engagement and happiness (see also Lancioni et al. 2011). Findings regarding increased indices of happiness and engagement are an important extension of previous work in teaching choice making in that they provide some indication that teaching choice-making can indeed contribute to one’s quality of life (Burke et al. 2020, Carr et al. 2002).

In addition to helping individuals make simple choices, concurrent-chains arrangements can also be used to facilitate making broader decisions about behavioral services, such as the types of behavioral interventions one may prefer to experience (see Hanley 2010). Behavioral interventions typically specify how helping professionals should arrange environments and react when an individual engages in challenging behavior or desirable behavior, commonly referred to as differential reinforcement (Petscher et al. 2009). When options exist pertaining to which type of differential reinforcement to arrange for an individual, we are asking them to discriminate between complex, dynamic interactions between their behavior and the consequences it produces. When concurrent chains procedures are used to examine more abstracted preferences, initial selections (e.g. ‘pick door 1, door 2, or door 3’) grant the individual access to another context in which a specific behavioral intervention (e.g. noncontingent reinforcement) is arranged. Repeated opportunities to make such selections permit an individual to express preferences regarding how they would like to interact with others and how they would like to be treated. Several studies have successfully utilized the concurrent chains procedures to determine preference for behavioral intervention by first requiring that the individual make each selection and subsequently requiring that they experience the intervention associated with each selection (e.g. DeLeon et al., 2001, Frank-Crawford et al. 2019, Slaton and Hanley 2016). Initial exposure trials are often considered a critical component to ensuring that subsequent choices reflect actual preferences as opposed to indiscriminate selections.

To address the lack of research incorporating the teaching of choice-making skills into daily routines, Deel et al. (2021) taught choice-making within a visual activity schedule to children with autism receiving services in a community-based center for early intensive behavioral intervention. Deel et al. (2021) ultimately sought to evaluate whether incorporating choice-making into activity schedules was preferred to being asked to complete a schedule devoid of options, but they importantly introduced procedures that were successful in teaching children to follow a schedule that included tasks that involved choosing an activity to engage with next. Procedures involved prompting the children through an activity schedule and using error correction if the child emitted an incorrect response (or did not respond to a particular step in the schedule). In other words, children were taught a follow a schedule inclusive of choice points and were corrected and prompted through steps for which they required assistance (e.g. not making a choice when the schedule indicated an option). Incorporating choice-making into daily routines seems to serve multiple purposes: It (a) increases opportunities to teach choice-making skills, (b) increases the overall choice-making opportunities offered to individuals with IDD, and permits both (a) and (b) to occur without dramatically interfering with one’s daily expectations and activities.

Is forced exposure necessary to teach choice?

Components to teaching choice making commonly involve introducing an individual to different stimuli from which they will select by way of a simple and discrete response, exposing them to the outcomes of those selections, and subsequently providing the options concurrently and repeatedly. It is important to note that procedures that teach choice-making skills critically involve prompting or otherwise requiring the individual to ‘experience’ the outcomes of their choices, which has been shown to facilitate choice making, but may not embrace the underlying spirit of promoting choice from a TIC perspective. As we argued above, exposure to the outcomes of our choices is important to facilitate discrimination among options, but there may be known or undetermined aversive properties of certain options that inhibit choosing those options. Contemporary approaches to promoting choice must reckon with the notion that many evidence-based approaches to teaching choice-making involve ‘forced exposure’ to unknown stimuli or situations. We argue that it is of paramount importance to allow individuals to disengage with such situations if they appear to be causing distress or discomfort. In some cases, this may involve facilitating disengagement by removing the stimuli upon early signs of distress and reinstating a more preferred environment (e.g. Rajaraman et al. 2022).

When should choices be provided?

Individuals with IDD and their advocates suggest that choice should be incorporated across multiple life domains with great regularity, and the choice-making literature has largely validated those recommendations. The literature is replete with examples of the types of choice-making opportunities that have facilitated participation, cooperation, and engagement with others’ expectations as well as summaries of those examples (e.g. Cannella et al. 2005, Kern et al. 1998, Shogren et al. 2004). Rather than list the myriad types of choices that could be provided in instructional contexts as per previous research (e.g. the order of activities, the location or manner in which to complete an activity), we suggest that helping professionals reflect on how they currently arrange instructional environments and consider incorporating choice-making opportunities wherever they reasonably can. Indeed, Howell et al. (2019) concluded that ‘a behavioural intervention that includes choice is quick and easy to implement, requires no special resources or training, and benefits individuals, particularly those with disabilities, in terms of facilitating increased communication, accounting for changing preferences, and allowing greater autonomy’ (p. 81).

The literature is less clear regarding when choices might be particularly important. Therefore, we defer to our collective clinical experience, which suggests that the provision of choice should be programmed from the outset of services. Transitioning to a new educational or residential setting can be overwhelming for many reasons, and has the potential to be traumatizing (e.g. permanent loss of contact with previously familiar individuals; Rajaraman et al. 2022). The immediate imposition of instructions and goal-oriented expectations without any provision of choice can exacerbate potential trauma by removing one’s autonomy. Instead, we recommend following the lead of the individual to the extent possible to help them feel safe and comfortable in a new setting prior to initiating any instruction. Doing so can provide clues to preferred events and activities and may increase their future likelihood of cooperation with adult instruction (Howell et al. 2019, Rajaraman et al. 2022).

Many service settings may already adhere to this recommendation to the extent that they conduct preference assessments with clients at the commencement of services. We suggest two considerations aimed at enhancing one’s ability to self-advocate in a new setting. First, conducting preference assessments regularly, as opposed to a single administration at the onset of services, may provide a better indication of preference. DeLeon et al. (2001) demonstrated the importance of offering choices regularly (e.g. daily) by comparing the efficacy of high preference stimuli identified from an initial preference assessment to those identified during brief daily assessments of preference. Results indicated that items determined to be of higher preference in daily assessments not only differed from those identified in the initial assessment but were also more efficacious when arranged as reinforcers. In a broader review of the preference assessment literature, Cannella et al. (2005) verified the intuitive notion that preferences may change over time for some individuals, further confirming the need for more frequent assessment. Taken together, these findings provide a strong rationale for routinely offering opportunities for individuals to make choices and thereby express their preference throughout the duration of their care.

Second, allowing clients to simultaneously experience multiple preferred items may be a better tactic than presenting stimuli in isolation. In many research preparations, evaluations of preference are assessed between or among singular items (e.g. one cookie against one cracker) or singular activities (e.g. one tablet against one action figure), whereby a selection of one item results in the removal of all other items. Although these arrangements provide important information about relative preference, it does not provide an indication of the reinforcing value of combinations of those items. For example, an individual may routinely select a tablet over an action figure, but that same individual might find watching videos on their tablet with an action figure in hand (and perhaps with a snack to top it off) more preferred than any of those stimuli in isolation. Further, granting multiple items simultaneously allows them to make moment-to-moment decisions regarding what to engage with while also allowing for potentially novel leisure engagement (e.g. role-playing with a Thor action figure while watching a Thor trailer). In other words, providing multiple items and activities to individuals, either during leisure periods or to be earned as reinforcers, is a general strategy that permits the individual to make choices that are untethered to the care providers with whom they are interacting. Rather than removing other items while the individual engages with one preferred item, providing multiple items simultaneously—to the extent that resources allow—affords the individual greater control.

What about the choice to participate?

Perhaps the most meaningful recommendation we can offer, particularly in light of the TIC and PBS values upon which this guide is based, and that cuts across all above recommendations, is to routinely offer individuals the choice to participate in their behavioral services or not. This may be the most immediately meaningful way to allow individuals to gain autonomy and self-advocate while expressing their lack of preference for the services we arrange for them. Allowing individuals to disengage with services at any time teaches them that they are safe in your care and that you acknowledge their autonomy. Importantly, it also serves as a useful indication that the context you have arranged may not be preferred for some reason or the other, which should engender problem solving and environmental modification to facilitate future engagement.

Is it possible to have too much choice?

Although increasing choice opportunities is consistent with promoting autonomy and self-determination, there is some evidence that suggests having too many choice options may leave people feeling despondent and depressed (Iyengar and Lepper 2000). Some individuals with IDD have acknowledged that having too many choice options produces anxiety and feelings of being overwhelmed (Lynn 2012, Wrong Planet Forums 2015). Luke et al. (2012) provided suggestions for reducing choice-induced anxiety, including (a) providing additional time to reach a choice, (b) minimizing irrelevant information, (c) presenting closed questions, (d) offering encouragement and reassurance, and (e) addressing general issues around anxiety. In addition to these suggestions, practitioners might also consider reducing the number of concurrently available options if they observe that individuals appear ‘stuck’ or distressed when choosing. This adjustment may ameliorate ‘overwhelming’ feelings but need not result in the permanent removal of certain options. For example, if choosing among 10 leisure activities appears difficult, it may be helpful to reduce the number of options available during any given choice, while still rotating options across choices.

Other difficulties with providing choice-making opportunities may arise when an individual displays challenging behavior in the presence of choices or otherwise cannot tolerate when choices are not provided. Indeed, challenging behavior can be evoked by situations where options are not available and subsequently reinforced by the immediate provision of choices (Rajaraman and Hanley 2021). When an individual struggles to navigate the unpredictability of when choices are offered, and particularly when such situations evoke dangerous behavior, service providers may be inclined either to ensure that sufficient choices are always available (which may be resource intensive) or to never arrange choice-making opportunities to avoid conflict (which may limit the person’s self-determination). Neither situation is likely sustainable, particularly if the individual transitions to a new service setting where a similar level of choice-making opportunities cannot be maintained (e.g. from home to school).

Difficulties around the provision of choice may point to a lack of concurrent interventions aimed at improving resiliency skills, such as coping with aversive situations and behaving effectively in their presence. A growing body of research has evaluated delay and denial tolerance training procedures that involve explicitly denying certain requests (e.g. ‘no you cannot play on the computer right now’), prompting a specific alternative response (e.g. ‘that’s no problem’), and reinforcing the tolerance response with the initially requested activities (e.g. Hanley et al. 2014, Ghaemmaghami et al. 2016, Rajaraman et al. 2022). Delay and denial tolerance training procedures have repeatedly been shown to promote skills that help individuals cope with the unavailability of certain options and choose to engage with alternative activities during delay periods. We argue that prioritizing coping skills and arranging explicit opportunities to practice them could serve as an important protective factor against later difficulties in the absence of choices. Moreover, emphasizing skill development in problematic contexts is aligned with the values and commitments of TIC, in that it serves to empower individuals to navigate and overcome unavoidable challenging situations they may encounter.

Conclusion

Although there may be practical barriers to incorporating meaningful choice-making opportunities in behavioral services, the short- and long-term advantages for providing such choices are evident. Indeed, choice making is an essential repertoire associated with several fundamental human rights accorded to all individuals (CRPD 2006b; Schloss et al. 1993). How to meaningfully incorporate choice-making opportunities for individuals with IDD on a day-to-day basis, however, may be less evident. We posit that practitioners can and should prioritize teaching choice making and providing choice-making opportunities. A summary of common challenges associated with incorporating choice-making opportunities into behavioral services, and their possible solutions, is presented in Table 1. TIC frameworks strongly advocate for the promotion of choice and the development of skills in services provided to those who have experienced or may be at risk for trauma. Prevalence data suggests individuals with IDD are at differentially greater risk to have experienced trauma (Rajaraman et al. 2022), so strategies that mitigate that risk, and appear to be aligned with PBS values such as person-centered planning, seem particularly important to incorporate into behavioral services.

Table 1.

Some recommendations pertaining to common challenges associated with choice provision in behavioral services.

Topic	Challenge	Recommendation	Relevant Citation(s)
How can we facilitate choice making?	Individual appears to not detect difference among options	Ensure that the individual experiences the outcomes of each choice option	Hanley et al. (1999); Higbee et al. (1999); Tessing et al. (2006)
		Use a concurrent chains arrangement involving a simple initial response (e.g. switch press) to facilitate discrimination	Hanley (2010); Stasolla et al. (2013)
	Multiple support programs are available, but individual’s preference among them is unknown	Use a concurrent chains arrangement where each terminal link represents a different support program	DeLeon et al. (2001); Frank-Crawford et al. (2019)
	Insufficient choice making opportunities across the individual’s day	Incorporate choice-making teaching opportunities into daily schedules and routines	Deel et al. (2021); Reid and Parsons (1991)
When should choices be provided during service delivery?	Care provider is generally unsure when to offer choices to individual	Incorporate as many choice-making opportunities as reasonably possible	Howell et al. (2019); Kern et al. (1998)
	Individual is commencing new behavioral services	Provide multiple choice-making opportunities, including the option to withdraw all participation, prior to initiating any instruction	Rajaraman et al. (2022)
		Conduct preference assessments regularly as opposed to a single administration at the outset of services	DeLeon et al. (2001)
		Allow individuals to simultaneously experience multiple preferred items (as opposed to singular items) during preference assessments	–
Is it possible to offer too much choice?	Individual appears to exhibit choice-induced anxiety	Provide additional time to make a choice	Luke et al. (2012)
		Minimize irrelevant information
		Present closed-ended questions
		Offer encouragement and reassurance
		Address general issues surrounding anxiety
	Individual displays challenging behavior when choices are not provided	Explicitly arrange opportunities to teach toleration and coping skills when choices are denied or otherwise unavailable	Hanley et al. (2014); Ghaemmaghami et al. (2016)
Is forced exposure necessary to teach choice?	Individual engages in challenging or avoidance behavior when being taught choice making	Provide the ongoing option to withdraw participation from the therapeutic context and offer concurrently available reinforcing activities	Rajaraman et al. (2022)

In a recent systematic review of the choice literature, Howell et al. (2019) reported that although a few choice-based interventions did not yield differentially greater performance when compared against ‘no-choice’ interventions (i.e. neutral results), no study reported any negative effects of incorporating choice. Said another way, according to the empirical literature examining choice-based intervention components, there does not appear to be a compelling reason not to promote choice in behavioral services. Incorporating choice-making opportunities in antecedent- and consequence-based interventions appears to be an effective and preferred strategy.

Disclosure statement

No potential conflict of interest was reported by the authors.